# Neonatal Tetanus > Neonatal tetanus for NEET-PG Paediatrics: inability to suck, spasms, spatula test, umbilical sepsis source, immunoglobulin and intensive care. - Canonical URL: https://prepelephant.com/topics/neet-pg/paediatrics/neonatal-tetanus - Exam / course: NEET-PG · Subject: Paediatrics - Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team - First published: 2026-10-02 - Last updated: 2026-10-02 - How to cite: "Neonatal Tetanus", PrepElephant, https://prepelephant.com/topics/neet-pg/paediatrics/neonatal-tetanus ## Direct answer Loss of the ability to suck on day five to fourteen of life in an otherwise normal, home-delivered newborn — progressing to rigidity, trismus, risus sardonicus and stimulus-triggered spasms — is neonatal tetanus: Clostridium tetani spores infecting an umbilical stump managed unhygienically in a mother with no tetanus immunisation. The diagnosis is clinical, and the spatula test is positive when a spatula touched to the pharynx provokes masseter spasm and biting instead of a gag. Management is intensive — human tetanus immunoglobulin, metronidazole, wound toilet, minimal-stimulation nursing, antispasmodics, airway protection and nutrition — and case fatality stays high, which is why the disease is judged a failure of maternal immunisation, not a therapeutic challenge. ## What you must remember - **Timeline to quote:** incubation 3-14 days after birth (shorter onset-to-spasm intervals predict worse outcome); the child feeds normally for the first days, then refuses the nipple — inability to suck is the earliest and commonest presenting sign. - **Clinical sequence:** suck lost first, then irritability and rigidity, trismus, risus sardonicus, opisthotonus, and spasms provoked by touch, noise or light; the infant remains conscious throughout — the diagnostic key. - **Source and epidemiology:** unhygienic cord practices — unsterile cutting instruments, application of ghee, ash, cow dung or turmeric to the stump — compounded by unimmunised mothers and home delivery without skilled attendance. - **Diagnostic test:** the spatula test — reflex masseter spasm on pharyngeal stimulation (biting the spatula) is positive in tetanus; a normal gag refutes it; there is no laboratory confirmation, culture is insensitive. - **Treatment package:** human tetanus immunoglobulin (about 500 units intramuscularly) to neutralise unbound toxin; metronidazole against the organism; umbilical toilet; nursing in a quiet, dim room with clustered care; diazepam or midazolam titrated to spasms, with morphine or magnesium if refractory; airway readiness and nutrition for the weeks of illness. - **Supportive imperatives:** sedate adequately but preserve spontaneous breathing where possible; aspiration pneumonia and umbilical sepsis are parallel battles; ventilation for severe spasms in referral centres. - **Prevention, the real answer:** two doses of tetanus toxoid (or Tdap) during every pregnancy at least four weeks apart (with a booster for subsequent pregnancies within five years) — maternal antibody crosses the placenta and protects the newborn; plus clean delivery and cord care practices. - **India's milestone:** maternal and neonatal tetanus elimination validated by the World Health Organization in 2015; sporadic cases still appear in pockets of vaccine hesitancy and home delivery, so vigilance remains examinable. ## How to work through it A seven-day-old, born at home with the cord cut by a village barber's blade and ash applied, is brought for "not taking the feed for a day". Observation for one minute shows the answer: a rigid infant who startles to voice with clenching of the jaw and brief opisthotonic arcs, a stump that is moist and foul. Minimal handling — quiet room, no undressing; bedside spatula test if spasms are not already evident; secure access for immunoglobulin and metronidazole; clean the stump; transfer to intensive care with diazepam for spasm control, escalating to midazolam or morphine. Tell the family honestly that the illness lasts weeks and the risk of death is substantial, immunise the mother, and audit the village for missed pregnancies. The prevention mirror is the exam's favoured ending: the same mother, pregnant again, receives two doses of tetanus toxoid at least four weeks apart and a clean-delivery plan; the newborn then carries passive antibody — which is how national elimination was achieved. ## How the exam frames it Two rules dominate. First, the conscious infant: tetanus, unlike encephalitis or meningitis, spares sensorium between spasms — and the differential from neonatal sepsis with meningitis, hypocalcaemic tetany and the rare neonatal dystonias is resolved by the cord story, the spatula test and the conscious, rigid, hyper-reflexic infant. Second, the prevention chain: the MCQ almost always reduces to which maternal intervention prevents the disease — tetanus toxoid in pregnancy — with the Indian elimination milestone (validated 2015) as the programme fact to quote. Metronidazole is preferred over penicillin (a gamma-aminobutyric acid antagonist that may aggravate spasms), and immunoglobulin neutralises only unbound toxin — hence early administration. ## Frequently asked questions ### What is the earliest clinical sign of neonatal tetanus? Inability to suck in an infant who fed normally for the first three to fourteen days, followed by rigidity, trismus and stimulus-provoked spasms with preserved consciousness. ### What is the spatula test? Stimulation of the pharynx with a spatula provokes reflex masseter spasm and biting in tetanus, instead of the normal gag reflex — a bedside-confirmatory sign. ### Why is metronidazole preferred over penicillin in tetanus? Metronidazole is equally effective against Clostridium tetani without penicillin's gamma-aminobutyric acid-antagonism, which can theoretically worsen spasms. ### How is neonatal tetanus prevented? Two doses of tetanus toxoid during pregnancy at least four weeks apart (boosters in later pregnancies), clean delivery and cord care — maternal antibody protects the newborn until active immunisation begins at six weeks. ### When was India declared free of maternal and neonatal tetanus? The World Health Organization validated India's elimination of maternal and neonatal tetanus in 2015, though surveillance for sporadic cases in unimmunised pockets continues.